Itch has many similarities to pain. They are both unpleasant sensory experiences - pain elicits a reflex withdrawal and itch leads to a scratch reflex. However, both can lead to serious impairment of quality of life. Pruritus is defined as the desire to scratch. It can be peripheral, due to stimuli occurring in the skin, or central, when itching is perceived as occurring in the skin although it originates in the central nervous system.
Itching may be associated with skin disease or have a systemic cause
Depending on the aetiology, a complex number of factors have been found that may be involved. Many different cells and mediators and modulators have been identified as having a role, both peripheral and central. Immune cells and glial cells may be involved to a greater extent than was previously thought. Agents which may be involved include histamines, leukotrienes, opioids, serotonin, cytokines (eg, interleukin-31), neuropeptides, itch-specific neurons and interneurons. Stress may also affect itch, along with the itch-reward cycle.
- This will depend on the underlying cause.
- Although itching is common and the vast majority of cases have an obvious and benign cause, it is essential to consider possible less common but serious causes. Examination should therefore include careful assessment of the abdomen and lymph nodes.
- Examination of the skin can help to elucidate the aetiology of the itch. A thorough examination may reveal lesions that the patient has not altered by scratching and therefore help in the diagnosis.
- Contact dermatitis.
- Dermatophytosis (tinea infections)
- Insect bites and stings.
- Atopic eczema.
- Pityriasis rosea.
- Dermatitis herpetiformis.
- Lichen planus.
- Lichen simplex chronicus.
- Senile atrophy.
- Prickly heat.
- Hepatic: cholestasis, especially primary biliary cirrhosis and drug-induced cholestasis.
- Endocrine: diabetes mellitus, hyperthyroidism, hypothyroidism, hyperparathyroidism.
- Renal: chronic kidney disease.
- Haematological: polycythaemia rubra vera, iron deficiency, myeloproliferative disorders.
- Neurological: multiple sclerosis, neuropathy, nerve root irritation or compression.
- Malignancy: Hodgkin's lymphoma, leukaemia, carcinoma (especially of the lung, prostate or stomach).
- Human immunodeficiency virus (HIV) infection.
- Drug allergies or side-effects (eg, opioid analgesics, allopurinol, amiodarone, statins).
- Psychological: obsessive states, schizophrenia, dermatitis artefacta.
A detailed history and careful examination are necessary to determine the cause. Any suspicion of systemic cause, lack of obvious cause for itching, or any patient with pruritus that does not respond to conservative therapy should be evaluated for underlying systemic disease.
- FBC, ESR, serum ferritin. (Iron-deficiency anaemia, polycythaemia, raised eosinophils in allergy. Raised white cell count in leukaemia and raised ESR in malignancy.)
- Fasting blood glucose.
- Renal function and electrolytes.
- Calcium, phosphate, alkaline phosphatase.
- TFTs: hypothyroidism or hyperthyroidism.
Referral may be required where an underlying cause has not been identified.
The treatment of pruritus is aimed at identifying and treating the underlying cause as well as symptomatic treatment for the itch. Symptomatic treatment is primarily aimed at keeping the skin moist and cool.
- Advise the patient to avoid scratching the skin and to keep their fingernails short. Wearing gloves at night and tapping the skin or drumming the fingers on the skin rather than scratching may be helpful.
- Cooling: simple measures to create a cooler environment, such as wearing light clothing and keeping cool in bed, may help. Avoid use of vasodilators (caffeine, alcohol, spices, hot water) and excessive sweating.
- Advise avoidance of irritants such as soaps, bubble bath and detergents. Cotton clothes are usually preferable to woollen clothes.
- Simple emollients may be effective when itching is associated with dry skin or in otherwise healthy elderly people. Advise liberal application as often as is required.
- Preparations containing crotamiton (eg, Eurax®) are sometimes used but are of uncertain value. Alternatively, aqueous cream containing menthol 0.5% or 1% may be helpful for some people.
- Topical antihistamines and local anaesthetics are not recommended, as thay are not effective, or are only marginally effective and may occasionally cause sensitisation.
- Oral antihistamines may be effective but mainly in urticaria and insect bites where histamine is the main mediator. They are ineffective in most dermatoses and systemic causes. Sedating antihistamines may be useful for night-time use. (Note the 2015 warning about the risk of QT prolongation with hydroxyzine, and prescribing restrictions.)
Other treatments which are used, mostly with specialised dermatologist advice, for specific causes of itch include:
- Topical corticosteroids (inflammatory skin conditions such as eczema).
- Oral colestyramine. This is the treatment of choice for pruritus due to biliary obstruction but its effect may be temporary and it is only effective if biliary obstruction is incomplete. Rifampicin, opioid antagonists and selective serotonin reuptake inhibitors (SSRIs) are also used.
- Thalidomide and naltrexone (uraemia). Nalfurafine has been found effective for itch related to uraemia but is not available in the UK.
- Gabapentin (chronic kidney disease).
- Cimetidine and corticosteroids (Hodgkin's lymphoma).
- Paroxetine (paraneoplastic itch).
- Aspirin and paroxetine (polycythaemia vera).
- Indometacin (HIV-positive patients).
If these specific remedies fail, paroxetine and mirtazapine can be effective. Topical or systemic application of specific agonists such as cannabinoids or calcineurin inhibitors can influence neuroreceptors on sensory nerve fibres of the skin and suppress pruritus. Itch-selective neurons in the dorsal horn of the spinal cord can be targeted to inhibit the transmission of pruritus to the somatosensory cortex. Anticonvulsants, antidepressants and micro-opioid receptor antagonists interfere with the sensation of pruritus in the central nervous system.
Ultraviolet light therapy may be more effective than medication for itch in certain conditions, such as chronic kidney disease, HIV and some dermatological causes.
In localised pruritus the use of transcutaneous electrical nerve stimulation (TENS) may help in the short term. Acupuncture has been used for localised pruritus. Evidence for these options is anecdotal.
Psychological strategies such as habit reversal training, relaxation therapy, and cognitive behavioural therapy (CBT) may have a role in breaking the itch-scratch cycle and the management of chronic itch.
A number of novel agents are being explored in trials.
Itch is a distressing, subjective symptom that may interfere significantly with the quality of a patient's life.
Further reading and references
Seccareccia D, Gebara N; Pruritus in palliative care: Getting up to scratch. Can Fam Physician. 2011 Sep57(9):1010-3, e316-9.
Bolier AR, Peri S, Oude Elferink RP, et al; The challenge of cholestatic pruritus. Acta Gastroenterol Belg. 2012 Dec75(4):399-404.
Sanders KM, Nattkemper LA, Yosipovitch G; Advances in understanding itching and scratching: a new era of targeted treatments. F1000Res. 2016 Aug 225. pii: F1000 Faculty Rev-2042. doi: 10.12688/f1000research.8659.1. eCollection 2016.
Reamy BV, Bunt CW, Fletcher S; A diagnostic approach to pruritus. Am Fam Physician. 2011 Jul 1584(2):195-202.
Itch - widespread; NICE CKS, November 2015 (UK access only)
Hydroxyzine (Atarax, Ucerax): risk of QT interval prolongation and Torsade de Pointes; Medicines and Healthcare products Regulatory Agency (MHRA), April 2015
Levy C; Management of pruritus in patients with cholestatic liver disease. Gastroenterol Hepatol (N Y). 2011 Sep7(9):615-7.
Tominaga M, Takamori K; An update on peripheral mechanisms and treatments of itch. Biol Pharm Bull. 201336(8):1241-7.
Xander C, Meerpohl JJ, Galandi D, et al; Pharmacological interventions for pruritus in adult palliative care patients. Cochrane Database Syst Rev. 2013 Jun 96:CD008320. doi: 10.1002/14651858.CD008320.pub2.
Pogatzki-Zahn E, Marziniak M, Schneider G, et al; Chronic pruritus: targets, mechanisms and future therapies. Drug News Perspect. 2008 Dec21(10):541-51.
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